Original paper

Relationship between body mass index z-score and acne

severity in adolescents: a prospective analysis

Bahar Öztelcan Gündüz1, Hatice Ataş2

Department of Paediatrics and Gülhane Research and Training Hospital, Ankara, Turkey
1

Department of Dermatology, University of Health Sciences, Ankara Diskapi Education and Research Hospital, Ankara, Turkey
2

Adv Dermatol Allergol 2023; XL (6): 808–813

DOI: https://doi.org/10.5114/ada.2023.133468

Abstract
Introduction: Acne vulgaris is a prevalent skin disorder influenced by a variety of factors, including a high body
mass index (BMI) and obesity.
Aim: To investigate the association between BMI z-scores and acne severity in boys and girls aged 10–18 years.
Material and methods: A 72-patient prospective analysis was performed, in which patient weight, height, body
mass index (BMI), body mass index z score (BMI z-score), percentiles, and demographic information were collected,
and acne severity was categorized as mild or moderate/severe.
Results: The results indicated that patients with moderate/severe acne were significantly older and had higher
weight, height, BMI, and BMI z-scores than those with mild acne (p < 0.01).
Conclusions: The findings suggest that higher BMI z-scores are linked to increased acne severity. These results
emphasize the importance of addressing weight-related risk factors for the prevention and treatment of acne
vulgaris. The early detection and management of weight-related conditions can play a crucial role in improving the
overall well-being of individuals with acne, considering its negative impact on mental health and social functioning.
Key words: acne vulgaris, body mass index, overweight, obesity.

Introduction as underlying factors. Additionally, dietary habits and en-

The global prevalence of overweight and obesity is
on the rise, affecting individuals of all ages. Particularly,
the prevalence of overweight or obese children and ado-
lescents aged 5–19 has significantly increased from 4%
to 18% between 1975 and 2016 [1]. This upward trend
holds substantial implications for public health. Acne vul-
garis, the most prevalent skin condition worldwide [2],
predominantly affects the pilosebaceous units on the
face, chest, and back. It stands as the predominant der-
matological issue among adolescents and young adults,
impacting over 85% of individuals in Western countries
[3]. While prior research has illuminated various facets of
acne, there remains a notable gap in our understanding
regarding the potential relationship between overweight/
obesity and acne severity. In Turkey, the reported preva-
lence of acne among teenagers aged 13–19 is 60.7% [4].
Despite uncertainty about the precise pathophysiology of
acne, it is acknowledged to involve genetic susceptibility,
hormonal imbalances, and sebum production disruptions
vironmental influences may contribute to acne develop-
ment [5, 6].
One important tool used to assess weight status
relative to peers is the body mass index (BMI) and BMI
z-score. The BMI z-score indicates whether a child’s BMI
is above or below the mean for their age and sex, con-
sidering standard deviations [7]. Previous research has
shown a correlation between BMI z-scores and adverse
alterations in body fat and lipid profiles, indicating an
increased propensity for adiposity in hyperlipidemic
children [8]. Excessive body fat, or adiposity, has been
proposed as a contributing factor to acne development
by influencing insulin and insulin-like growth factor-1
(IGF-1) levels. Insulin and IGF-1 are hormones responsible
for regulating glucose metabolism and cellular growth,
respectively. Elevated levels of these hormones can stim-
ulate the production of sebum, an oily substance that
contributes to the development of acne. Moreover, they
may also facilitate the growth of skin cells and the pro-

Address for correspondence: Bahar Öztelcan Gündüz MD, Aşağı Eğlence Mahallesi, Gülhane Eğitim Araştırma Hastanesi, Çocuk Sağlığı
ve Hastalıkları Bilim Dalı, Keçiören, Ankara, Turkey, 06600, phone: +90 5055657029, e-mail: baharoztelcangunduz@gmail.com
Received: 18.09.2023, accepted: 26.10.2023.

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0).
License (http://creativecommons.org/licenses/by-nc-sa/4.0/)

808 Advances in Dermatology and Allergology 6, December/2023

 Relationship between body mass index z-score and acne severity in adolescents: a prospective analysis
liferation of Propionibacterium acnes, a bacterium com-
monly associated with acne [9].
Given the possible association between the severity
of acne and an individual’s weight status, the primary
objective of this study was to investigate how BMI, per-
centile, weight, and height relate to acne severity in boys
and girls aged 10–18.
Aim
Our purpose in conducting this research was to con-
tribute to an improved comprehension of the complex
relationship between weight status and dermatologi-
cal health, with the ultimate goal of providing valuable
insights for more effective strategies in managing and
preventing acne.
Material and methods
This prospective study assessed children aged 10–18
years who visited the general paediatrics department with
acne concerns and were then referred to the dermatology
department for evaluation. At the dermatology visit, the
patients received a diagnosis of acne vulgaris (the most
common form of acne) made by a board-certified der-
matologist based on visual skin examination. To quantify
acne severity in an objective manner, the dermatologist
utilized the Global Acne Severity Scale (GEA Scale) [10].
This is a validated assessment tool for acne that assigns
numerical severity scores based on the number and type
of lesions present across different facial regions. Global
Acne Severity Scale (GEA Scale) categorizes acne lesions,
including comedones, papules, pustules, and nodules, and
assigns severity levels based on their presence and extent.
Higher scores indicate more severe acne.
In addition to the dermatological evaluation, anthropo-
metric measurements including height, weight, BMI and
BMI percentiles adjusted for age and sex were obtained
from each patient. Weight was measured using a medical-
grade digital scale calibrated according to standard proce-
dures. Patients were asked to remove their shoes and heavy
outer clothing. They then stepped on the scale platform,
which displayed their weight in kilograms to one decimal
place. After the person to be measured stood upright with
their back straight and head in a neutral position, with eyes
looking forward, the measurement was taken from the top
of the head downward using a measurement device or the
measurement lines on a wall. For quality control, the scale
was checked using known weights at the start of each study
day. The scale measurements were recorded directly into
the patients’ study files.
The data were recorded in the hospital information
system, and forms retrieved from the system between
1 September 2022, and 1 December 2022 were reviewed.
Patients with documented endocrine disorders, hormonal
imbalances, a history of medication use, a diagnosis of
Advances in Dermatology and Allergology 6, December/2023
polycystic ovarian syndrome, or insulin resistance were
thoughtfully excluded from the analysis. To quantify the
weight status and body mass of the patients, we har-
nessed the power of ChildMetrics©, a specialized applica-
tion thoughtfully developed by the Turkish Pediatric Endo-
crinology Association, specifically designed to cater to the
unique anthropometric nuances of Turkish children [10, 11].
The patients were categorized based on the severity
of their acne. We formed two groups: Group 1 consisted
of individuals with mild acne, whereas Group 2 com-
prised individuals with moderate to severe acne.
All of the people who took part and their families
volunteered, and the treatments were done according to
the rules of the local ethics committee and with Gülhane
Training and Research Hospital, Gülhane Scientific Re-
search Ethics Committee approval (2022-279). After be-
ing informed about the study, informed written consent
was obtained from the parents of the children. The pro-
cedures followed in this study were conducted in strict
accordance with the ethical principles outlined in the
Helsinki Declaration of 1975, as revised in subsequent
editions. All aspects of patient recruitment, data collec-
tion, and analysis were carried out with utmost consid-
eration for the well-being, privacy, and informed consent
of the participants.
Statistical analysis
Frequency, mean, median, and percentage were used
to compare the data, and Kolmogorov-Smirnov and Sha-
piro-Wilk tests were used to examine the normal distri-
bution of the data. The Mann-Whitney U test, Student’s
t-test, and c2 test were used to compare the groups, and
those with p < 0.05 were considered significant. Logistic
regression analysis was used to identify the risk factors.
In univariate analyses, those with p < 0.01 were included
in the multiple regression analysis, and those with p <
0.05 were considered significant.
Results
The mean age, height, weight, acne severity, percen-
tile score of weight, median BMI and BMI z-score, and
median weight z-score of participants were 14.7 ±1.8
years, 165.0 ±8.3 cm, 59 ±10.16 kg, 2.61 ±0.76, 67.7 ±16.0,
21.1, 0.08 and 0.1 respectively (Table 1). A significant
association was found between acne severity and the
BMI, BMI z-score, weight z-score, and percentile score
(p < 0.001) (Table 2). Group 2 children also had a higher
mean weight (64 ±7.72 kg) compared to Group 1 (53.9
±9.29 kg) (p < 0.001). Group 2 children had a higher mean
BMI (20.23 ±1.62 kg/m2) compared to Group 1 (22.9 ±1.80
kg/m2) (p < 0.001). Group 2 (Moderate + Severe Acne)
showed statistically significant differences compared to
Group 1 (Mild Acne) in terms of weight and BMI z score
(p < 0.001) (Table 2).
809
Bahar Öztelcan Gündüz, Hatice Ataş

Table 1. Demographic data of patients (n = 72) Discussion

Parameter Mean ± SD* Median Range This study focused on children aged 10–18 with acne,
Age 14.7 ±1.8 15 11–18 analysing various anthropometric measurements, BMI-
related parameters, and acne severity. The results high-
Height 165.0 ±8.3 166 145–180
lighted a significant association between acne severity
Weight 59 ±10.16 58 35–80 and BMI, BMI z-score, weight z-score, and percentile
Severity 2.61 ±0.76 2 2–5 score. These findings suggest that promoting healthy
BMI [kg/m ] 2
21.5 ±2.18 21.2 16.7–26.4 weight maintenance may positively affect acne severity
in adolescents.
Percentile⸸ 67.7 ±16.0 69 27–93
The correlation between BMI and acne is currently
Height z-score** 0.14 ±0.66 0.09 (–) 1.60–1.82 without scientific consensus, mired in controversy due
Weight z-score 0.15 ±0.66 0.1 (–) 1.65–1.65 to unclear underlying mechanisms. Nonetheless, several
BMI z-score 0.14 ±0.62 0.08 (–) 1.1– 1.46 theories have been posited to explore this potential as-
sociation. Obesity increases adipose tissue, where an-
Parameter n %
drogen is synthesized, leading to hyperandrogenism [12].
Gender Male 36 50 Androgens stimulate the sebaceous gland; thus, hyperan-
Female 36 50 drogenism leads to increased sebum production, result-
*SD – standard deviation. Percentile⸸: The percentile value indicates the rela- ing in acne [13, 14]. Obesity can affect acne development
tive position of an individual’s measurement compared to the distribution of in several ways. Obesity has been suggested to lead
measurements in the reference population. The resulting z-score** indicates
how many standard deviations a data point is away from the mean. to an increase in androgen levels, which are hormones
known to stimulate sebum production, a key factor in the
pathogenesis of acne [15].
The z scores for weight, and BMI did not show sig- Various studies have suggested an association be-
nificant associations with the outcome variable in either/ tween obesity, androgen levels, and the severity of acne
any of the multiple regression analyses. The significant in women. For instance, Alan et al. reported a higher
associations observed in the multiple regression analy- prevalence of hyperandrogenism and obesity in women
ses remained consistent for BMI. The odds ratio for BMI with acne, with a positive correlation between BMI and
remained at 2.5 (OR = 2.5), with a 95% CI of 1.6-3.7, and acne severity. Similarly, Borgia et al. identified a nega-
the p-value remained < 0.001 (Table 3). tive correlation between acne severity and serum sex

Table 2. Comparison of children from Group 1 (Mild Acne) and Group 2 (Moderate + Severe Acne)
Parameters Units Group 1 (n = 39) Group 2 (n = 33)

Mean ± SD Median Range Mean ± SD Median Range P-value

Age years 14.1 ±1.90 14 11–18 15.3 ±1.36 15 13–18 0.04
Height cm 162.6 ±8.29 162 145–180 168 ±7.43 169 149–180 < 0.001
Weight kg 53.9 ±9.29 54 35–78 64 ±7.72 65 53–80 < 0.001
Severity 2 ±0.0 2 2–2 3.3 ±0.5 3 3–5 < 0.001
BMI kg/m 2
20.23 ±1.62 20.0 16–24 22.9 ±1.80 23.0 20–26 < 0.001
Percentile P 60.7 ±15.01 63 27–85 76 ±13.2 78 36–93 < 0.001
Percentile AN/N 1.02 ±1.16 1 1–2 1.3 ±0.47 1 1–2 < 0.001
category
Height z-score 0.18 ±0.69 0.09 (–) 1.51–1.82 0.09 ±0.63 0.02 (–) 1.60–1.29 0.59
Weight z-score –0.13 ±0.56 –0.09 (–) 1.65–0.84 0.49 ±0.61 0.53 (–) 1.1–1.65 < 0.001
BMI z-score –0.18 ±0.42 –0.15 –1.1+0.45 0.51 ±0.6 0.51 (–) 0.94–1.46 < 0.001
Parameter n % n %
Gender Male 17 43.6 19 57.6 0.23
Female 22 56.4 14 42.4
AN – abnormal, BMI – body mass index, N – Normal, SD – standard deviation.

810 Advances in Dermatology and Allergology 6, December/2023

 Relationship between body mass index z-score and acne severity in adolescents: a prospective analysis
Table 3. Evaluation with multiple regression analyses
Parameters Units Univariate analysis
P-value
Age years
Gender M/F 0.24
Height cm 0.008
Weight kg < 0.001
BMI kg/m2 < 0.001
Percentile P < 0.001
Percentile category AN/N 0.006
Height z-score 0.59
Weight z-score < 0.001
BMI z-score < 0.001
AN – abnormal, BMI – body mass index, N – normal, SD – standard deviation.
hormone-binding globulin (SHBG) levels, indicating a link
between peripheral hyperandrogenism and acne sever-
ity. Additionally, Yang et al. observed that obese women
had a lower incidence of acne compared to non-obese
women, despite having higher serum testosterone levels
[16–18].
This relationship becomes particularly important
when considering the multifaceted effects of acne vul-
garis. The presence of acne can lead to significant altera-
tions in sex hormones, serum lipids, metabolic status,
and BMI. However, Gayen et al. [19] found that female
patients with acne vulgaris had altered sex hormone
levels, including elevated testosterone and progesterone
with low oestrogen. Wang et al. [20] also found higher
levels of testosterone, androstenedione, and dehydro-
epiandrosterone-sulfate in women with acne vulgaris
compared to controls. These findings suggest that hyper-
androgenemia may play a role in the development and
exacerbation of acne vulgaris.
The effects of obesity and hormonal factors on acne
severity may differ depending on one’s age and develop-
mental stage. While current evidence offers preliminary
links between weight measures, levels of sex hormones
and severity, their roles may vary at different develop-
mental periods. An especially prudent analytical ap-
proach would be to examine groups across different life
stages (paediatric, adult, gender-specific) in a longitudi-
nal framework.
The relationship between BMI and acne has been
investigated by several researchers in children. Kar-
ciauskiene et al. found that children with higher BMI had
a higher prevalence of acne [21], Anaba et al. reported
a similar trend in adolescents, with a higher prevalence
of acne in those with higher BMI [22], Lu et al. [23] also
found that patients with moderate to severe acne had
a higher mean BMI compared to controls. However, Tsai
et al. [24] showed that the mean BMI of acne-free chil-
Advances in Dermatology and Allergology 6, December/2023
Multivariate analysis
OR 95% CI P-value OR 95% CI
1.5 1.1–2.1
0.6 0.2–1.4
1.1 1.1–1.2
1.2 1.1–1.3
2.5 1.6–3.7 < 0.001 2.5 1.6–3.7
1.1 1.1–1.2
19.1 2.2–157
0.8 0.4–1.7
6.3 2.3–17.8
14.3 3.8–53.5
dren was lower than that of children with acne. Snast
et al. [25] found an unexpected inverse association be-
tween overweight/obesity and acne in a nationwide
study of adolescents. The proportion of adolescents with
acne gradually decreased from underweight to severely
obese. Rodriguez Baisi et al. investigated the incidence of
acne in preadolescent girls and boys, and observed that it
was higher in girls and increased with age. Our findings
are consistent with those of previous studies that dem-
onstrated a link between BMI and acne development.
This study established a significant connection between
acne severity and variables including BMI, BMI z-score,
weight z-score, and percentile score. Nevertheless, it
is essential to acknowledge the research’s limitations,
such as a relatively small sample size and its restriction
to a single hospital, which may affect the broader appli-
cability of the results.
Rodriguez Baisi et al. found that preadolescents with
acne were more likely to be obese compared to those
without acne [26]. Tsai et al. study supported the posi-
tive associations between BMI and acne development,
and showed the severity of acne may start to worsen in
the upper grades of elementary school [27]. Tsai et al.
further supported the findings of Rodriguez Baisi et al.,
who demonstrated positive associations between BMI
and acne development. The study also indicated that
acne severity tends to worsen in the upper grades of el-
ementary school. Building upon these previous findings,
our own study included participants who had entered
puberty and were older than in both the Rodriguez Baisi
et al. and Tsai et al. studies. The consistent relationship
between age and acne severity, as observed in our study,
aligns with prior research findings. Age is a critical factor
to consider when evaluating acne as it may reflect not
only the natural progression of the condition but also
its potential connection to various underlying factors,
including weight status. Understanding the interplay
811
Bahar Öztelcan Gündüz, Hatice Ataş
of age, acne severity, and weight status is essential for
implementing effective acne management and treatment
strategies. Hence, a comprehensive assessment of sex
hormones is advisable for acne patients, irrespective of
the severity or symptom burden. Additionally, the pres-
ence of hirsutism can be a valuable clinical indicator for
lipid abnormalities and may serve as a marker for evalu-
ating the lipid profile in individuals with acne vulgaris.
Nevertheless, further research is imperative as the pre-
cise role of sex hormones in the pathogenesis of acne
vulgaris remains incompletely understood.
Controversial findings have been reported regarding
the association between an increased BMI and acne. It
is important to acknowledge that the relationship be-
tween an elevated BMI and the occurrence of acne has
yielded inconsistent and sometimes conflicting find-
ings. A study conducted by Gayen et al. concluded that
there was no link between acne and obesity, and meta-
bolic syndrome was not directly correlated with the se-
verity of acne [19]. A study of BMI and acne vulgaris in
180 students showed that individuals who were not
obese (31.7%) had the condition more frequently than
those who were overweight/obese (14.4%) [14]. Another
study conducted in 2018 showed that for all acne grades,
there was no relationship between BMI and acne sever-
ity [28]. In contrast to studies exploring the association
between dietary factors and acne, our study did not spe-
cifically examine such factors, which could be considered
a limitation. Nevertheless, the findings from these stud-
ies suggest that what we eat may play a crucial role in
the development and severity of acne rather than solely
focusing on the quantity of food consumed. More recent
analyses have provided support for this notion, particu-
larly with regard to the impact of dietary patterns, such
as a Western diet or a high-glycaemic-load diet, on acne.
These studies demonstrated that individuals following
a low-glycaemic-load (GL) diet exhibited lower androgen
concentrations and reduced sebum outflow, leading to
a decrease in acne severity [29, 30]. These two studies
may lead to the conclusion that what we eat may have
an impact on acne development and severity, rather than
how much we consume.
The evaluation of acne severity remains a complex
challenge due to the absence of a universally accepted
gold standard grading system. In this study, we utilized
the Global Acne Severity Scale (GEA Scale) to assess acne
severity, a choice that merits further discussion and explo-
ration of alternative methods. Global Acne Severity Scale
(GEA Scale) has been widely employed in dermatological
research and practice, offering a structured and compre-
hensive approach to assessing acne severity. However, it
is essential to acknowledge the limitations of this scale. It
may not capture the full complexity of acne severity, po-
tentially leading to variations in grading based on different
observers and populations. Our study recognizes this limi-
tation, and several other grading scales, such as the Global
812
Acne Grading System (GAGS), the Investigator’s Global
Assessment (IGA), and the Leeds Revised Acne Grading
System, offer alternative perspectives on acne severity
assessment. Moreover, the multifactorial nature of acne
underscores the importance of considering other etiologi-
cal factors that influence its development and severity. Our
study focused on the association between BMI z-scores
and acne severity, but we acknowledge that familial his-
tory, metabolic disorders, and dietary habits can also play
significant roles in the pathogenesis of acne.
The sample size of 72 patients is relatively small, and
the study was conducted at a single hospital in Turkey.
Another limitation is that other acne etiological factors,
such as familial history or metabolic disorders, were not
considered in our study.
One strength of our study lies in the investigation of
the relationship between BMI z-scores and acne sever-
ity. While we did not specifically examine dietary factors
like the studies mentioned earlier, our focus on exploring
the correlation between BMI z-scores and acne severity
provides a valuable contribution to the existing body of
knowledge. By examining this specific aspect, we aimed
to further understand the impact of weight status on
acne severity among our study participants.
Such a relationship has a significant impact on the
treatment of patients with acne as therapy should focus
not only on the proper selection of medications, but also
on the modification of the patient’s dietary habits, physi-
cal activity, and, if necessary, reduction of body weight.
The study’s results could inform about the development of
weight management programs for individuals with acne,
or prompt dermatologists to consider a patient’s weight
status when developing treatment plans for acne vulgaris.
Future studies aimed at illuminating such potential
variations would benefit from considering influences like
genetic background and ethnicity, which likely impact
severity. Gaining a deeper understanding of the complex
relationships between physiological characteristics and
how acne presents itself necessitates investigations that
account for a myriad of interrelated influences over one’s
lifetime. This methodology could help successfully dis-
entangle the many overlapping influences likely at play.
Separating obesity and hormone impacts according to
context promises to further clarify acne’s pathophysiology
or underlying medical causes. Only through comprehen-
sive long-term examinations of diverse populations can
we hope to distinguish between confounding issues and
achieve a more sophisticated comprehension of acne’s
multifactorial origin or numerous contributing factors.
Acknowledgments
The authors wish to thank all the participants and
their families for their valuable contributions when taking
part in the study. The authors also wish to state that the
views expressed in this article are those of the authors.
Advances in Dermatology and Allergology 6, December/2023
 Relationship between body mass index z-score and acne severity in adolescents: a prospective analysis
Conflict of interest
The authors declare no conflict of interest.
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